A letter

I'm still angry at the government.

But at least one MP understands what I mean: Famous Green Caroline Lucas has sponsored a sympathetic early day motion http://www.parliament.uk/edm/2015-16/539, so I wrote a letter to my MP at www.theyworkforyou.com to bring it to his attention.

                              


                                        Tuesday 20 October 2015

Dear My Local MP,

I have recently moved to constituency to begin work as a junior doctor
at hospital, and so have become one of your constituents. I am writing to
ask for your support in opposing recent changes to doctors' working
conditions and further to express my disappointment in the current
government's handling of the NHS.

I am sure you are well aware of the collective anger felt by doctors at
prospective contract changes. Much opinion and analysis has been
published in the national press, as well as on social media. I expect
many doctors will have written to you before now and you will have no
doubt seen coverage of the large demonstration in London last weekend.

I speak for many of my colleagues in stating that I believe the imposed
changes are damaging for a great number of reasons. The proposed
contract devalues doctors, patients and the NHS. 

The contract fundamentally changes the way doctors get paid, such that
they would expect no increased pay for working evenings or Saturdays.
This  allow rota managers to significantly worsen the working
conditions of all doctors, and will result in a significant pay cut for
doctors already working difficult rotas.

The contract would remove safeguards against doctors working long
hours. Doctors could be coerced into routinely working longer than
their contracted hours, further demoralising and fatiguing those in the
profession.

The reason for this change appears to be to work towards a 7 day health
service. The benefits of a full 7 day (elective, as emergency cover is
already 7 day) NHS has been grossly overstated by the government. Many
people would welcome the huge increase in staff (and funding) required
to achieve a full 7 day service, but unfortunately there has been no
suggestion of this.

Without extra funding and extra staff the alternative solutions would
be either pulling doctors out of their weekday jobs to cover the
weekends - and the NHS is already straining to operate Monday to Friday
- or increasing the working week of doctors by approximately 40% more
hours. Both are directly harmful to doctors and patients. The contract
would also pave the way for other healthcare professionals to be
expected to work at the weekend and/or face (further) pay cuts
themselves so these concerns will be soon also directly felt by nurses,
consultants, porters, radiographers, ward clerks, physiotherapists and
so on, and on, and on.

There is already a large retention and recruitment crisis in the NHS.
Training positions in many specialities remain unfilled and demands of
patient care are only barely met with expensive and less efficient
locum staff. As doctors decide that the working conditions are no
longer tolerable then the working conditions for those remaining get
worse still as they must shoulder the annually increasing burden.
Obviously this situation is already bad for patient care, and the
problem will only be exacerbated as this contract will force many
doctors out of the NHS to better jobs in the UK or abroad.  I am very
concerned that an understaffed NHS will not survive much longer.

It is painful to watch as my profession and the NHS continue to be
undervalued, misunderstood and mismanaged. I do not have confidence in
the Secretary of State for Health's ability to protect the nations
health. I urge the Secretary of State to listen to his workforce and to
engage in meaningful talks. Unfortunately this has not occurred as yet
and many doctors feel forced to take the uneasy decision to vote for
industrial action in the coming ballot. I sincerely hope there can be a
strike-free resolution that allows doctors to feel valued, patients to
receive excellent care and shows investment in the future of the
National Health Service.

I strongly believe that the NHS is worth fighting for and so I would
like to ask your support for Early Day Motion 539: Junior Doctors (tabled
19/10/15), and also to ask what you and the Labour Party will do to protect
doctors, patients and the NHS.
Many thanks for listening to my concerns. I look forward to your reply.

Yours sincerely,

Dr O
MA MBChB 





On the 5th of November I got a fairly supportive copy paste reply, albeit vague and without reference to the Early Day Motion I asked support for.
 (re-copied and pasted here with names removed) 

Dear Dr 

Thank you for your recent email regarding junior doctor contracts.

The Labour Party is currently leading on this issue in the House of Commons. Last week, we secured an opposition day debate on the matter where we called for the Government to drop their plans for a new junior doctor contract. We also put forward new proposals which are fair for staff and safe for patients.

Ultimately, the Labour Party believes that it is wrong for the Government to want to pay some junior doctors less to do the work they do now. Labour is concerned that the removal of safeguards which prevent junior doctors having to work excessively hours may leave them too exhausted to provide safe patient care. Jeremy Hunt should recognise the increasing public concern on this issue, stop his high-handed demands and demonstrate a willingness to compromise and prioritise patient safety.

I can assure you that this issue is a priority of the Labour Party’s. In opposition, we will continue to follow this matter closely to hold the Government to account.

I have also offered to meet with a group of constituents and junior doctors who are concerned about this matter.

Please do not hesitate to contact me again if you feel that I can be of any further assistance with this or any other matter.

Yours sincerely

Judging the SJT

It has come to my attention that I am coming to the end of my last proper Christmas vacation. Friends and relatives are keen to remind me that next year, all being well, I probably won’t have two straight weeks off to binge on crisps and mince pies because I might have a job and responsibilities and other such nonsense. I take this realisation with great sadness as the student sloth has been my annual routine and identity for the last 24 years. But in order for this seismic transition from scrounger to “professional” to occur later this year (Happy New Year by the way), I need to first sit and pass the notorious SJT. This is the Situational Judgement Test, a confusing but essential hurdle to clear to be allocated a job.I wrote a bit about it here a few months ago when I summarised the application process and complained about having to apply for a job.

My exam is next Friday and so I figured it's about time to find out what the fuss is about. I soon realised that I was unable to adequately explain the SJT to various people that asked me, and this was a bit alarming since it is the main measure that decides whether I get to be a doctor in the NHS in August or not, and if so where.

What are SJTs and Why are they used? – according to the medical schools council. 

"Situational judgement tests are increasingly popular recruitment tools, a measurement method to assess judgement in work-relevant situations. They present challenging situations likely to be encountered at work, focusing on non-academic/professional attributes (e.g. integrity, empathy, resilience, teamwork)"

Questions go through a long process of piloting and amendment and are reviewed by psychologists and clinicians. Predictive validity for junior doctors has not been shown yet – the study will track the progress of the 2013 cohort.

SJTs are cost-effective methods to administer and score applicants compared to interviews, and are arguably fairer than essay-based application forms that can be filled out by candidate’s relatives, for example.An SJT has been used to select candidates for GP specialist training since 2007, and here they have been shown to be superior to both knowledge tests and high fidelity selection centres.

I don't really know what the arrows are for either

SJTs are also used in the FBI selection process.

The SJT also allows the system to find candidates that have severely deficient personal or professional attitudes; I will be embarrassed if I get revealed as a psychopath or a moron through taking this test. It is important to recognise the importance of practical intelligence in addition to academic intelligence in being a useful doctor. Book smarts are in books, and even morons and psychopaths can buy books and pass exams.

The SJT Practice Paper*

So I found the official practice paper online and spent a morning reading about it and then doing the test. Sitting the practice test kindled some strong emotions in me (frustration only) and I considered writing a tedious blow by blow account of my mood and thoughts. Mercifully I decided against this. So I’ll just make some sweeping statements about the questions in general to make excuses as to why I do so badly in it next week. I realise that my time will certainly have been better spent practising questions or reading GMC guidelines but I’ve started writing this now so oh well.

The test consists of 70 questions to be completed in 140mins. If my calculations are correct that’s about 2 minutes per question. My first thought was how unpleasantly the SJT scenarios portray working life. It seems that every other day I can expect to be undermined by various colleagues, or be bullied or shouted at. I also need to deal with the dangerous F1s, the infection spreading nurse, the fraudulent doctor, the shouting consultants, the drunk F1, the rude nurse, the various weeping junior doctors and the angry locum. Seven separate questions involve dealing with other F1s who refuses to do their job properly and dump extra work on me.

 The first 47 questions (about two thirds, about 94 minutes, using maths) consist of a paragraph describing a one ranks five statements in order of how appropriate they are for a given scenario. Each question is marked out of 20. Full marks are awarded if you get the order exactly “correct”, and marks are gained for getting it nearly right. For example you only lose two points if two adjacent options are switched. I think these questions are more subjective than the remaining 23 questions (choose three best options). 

The scoring system for the rank 5 in order questions

It seems to me that because the exam format is already quite artificial, the questions can never be completely unambiguous or completely fair. For some questions the order matters a great deal more than for others i.e. you could lose six marks when you risk patients dying on one question and lose six marks for finishing late on the next.

On the front of exam you can find the words “you may sometimes feel you would like more information before answering, but please answer each question based on the information provided”. Indeed in almost every single question I want more information. Without more information a candidate need to fill in the gaps sometimes, and so will be penalised if they do not make the same assumptions as the examiner. I need to correctly guess that a patients “breathing difficulty” is not an emergency and is best seen by a nurse, guess that the “Urdu speaking doctor” exists and is nearby and is free to help out when I could use his services, guess that my fictional F1 colleague would value the support of another when talking to a senior about his work-life balance, rather than find this embarrassing, patronising or an invasion of privacy. Usually guessing wrong will not have a large effect on the mark but it is still unfair that for some questions this will arbitrarily reduce the mark for some candidates.

For example one of the question calls for a candidate to choose to attend theatre for personal learning and experience ahead of checking a colleague’s prescriptions when a nurse has raised concerns about them because “Ensuring that the nurse’s concerns about errors are addressed is very important, but not immediate". I think this would be inappropriate if there were concerns that these errors endangered patients (100mg potassium cyanide PO STAT), but this important information is absent from both the question and mark scheme so one is supposed to err on the other side to caution and must assume that patient safety is not compromised to score 20/20.

Other questions do not clearly discern by what measure an option is deemed best: is it the gold standard time-consuming or expensive option that is most likely to result in a satisfactory outcome or the option that is easiest and quickest to do first? Is it the option that will definitively solve a problem long term or the option that will contribute most to patient care in the short term? For example there is a question asking what a junior doctor should do in the unlikely event that there is not enough work or training opportunities in his or her post. I think prompt discussion with the consultant and programme director is important to allow time to rectify this before the next rotation. The mark scheme suggests that one should first assist on other wards (and so this option comes before talking to the programme director), to me this is clearly what should occur to fill free time after the problem has been raised with seniors.

Some of the questions use the stem: “Rank in order the extent to which you agree with the following statements in this situation”. Honesty is apparently a desirable quality in junior doctors and I feel aggrieved that this question may require me to lie about how much I agree to get the best mark.

In over half of the practice paper questions I think it is possible to make a sensible and defendable case for an order other than that given in the mark-scheme. I therefore think it is false to have a definite single best order. In the practice paper there is usually a good option and a terrible option but sometimes options are equally good or bad. One shouldn’t lose marks if they rank the two terrible options (is it more wrong to stab the kitten or the puppy?) in the bottom slots but in an apparently incorrect order. In these cases it doesn’t make sense to order them if either order is arguably consistent with the ambiguities of the question and known best practice guidance (stab both simultaneously).

So finally to my conclusion: It is perhaps impossible to create a completely clear, cost-effective, perfect system for assessing 7000 candidates and suitably assigning them positions. It is important to show the importance of professional “soft” skills – in having an SJT test at all forces medical students to think about difficult situations and read the best practice guidance online. However, there is not enough precision in the SJT to use it to fairly stratify candidates with sufficient resolution to allocate jobs nationally.

*By all accounts the practice paper bears little to no resemblance to the actual SJT test so please continue to ignore everything I have said

How to Become an F1 Doctor - The Illusion of Choice

Some, including yours truly, may find it difficult to believe that in August 2015 I expect to begin life as a junior doctor. If everything goes to plan then I will nervously sweat and mumble and spread infection in a hospital – like what I currently do as a medical student, only more so (and with more direct consequences for the ill people I come into contact with).  

The most junior doctors in hospitals used to be called House officers, but since 2005 are now called FY1 doctors – because they are in the first of two years of the foundation programme. A complicated nationwide online system is used to match the 7000 or so applicants to their foundation programme jobs and hospitals. Put simply, each candidate ranks the available jobs in order of preference and is allocated one based on the number of points they can scramble together. Points mean prizes, and the prize here is precedence in allocation of your application choices.

I foolishly spend far more time complaining about the application process (see current whinging blog post) than actually thinking about my own application; the deadline is this week.  Now and then I become self-aware enough to feel a little ashamed of complaining and realise how good we have it as medical students; unlike almost every other degree programme in the UK nearly all of us that pass medical finals will get a job, somewhere. For the last four years there have been more applicants than jobs for them but for example last year in 2014 96% (7114)  where allocated jobs in the first round and places were eventually found for all 235 remaining on the reserve list.

So bearing that in mind, here is where I whinge at length about the system, conveniently grouping my complaints into two categories thus:

1) The points system is not perfect

Some jobs and some parts of the country are more desirable and therefore more competitive than others.  You can’t make every finalist happy (see current whinging blog post) and allocating randomly is clearly madness. So a system has been devised to rank students from best to worst such that the better get to go where they want and the worse have to go where they’re told. This is done by ascribing each student a score out of 100:

The educational performance measure (50 points max)

An applicant gets between 34-43 points for their decile in their medical school exams to date. I don’t think there’s a particularly strong correlation between exam score and competency as a doctor, common sense and teamwork and time management are more important than memorising textbooks (but maybe that’s me being defensive since I’m not top of the year by a considerable margin). Also some question whether the points awarded per deciles should be equivalent across all medical schools as is currently the case, despite different entry standards, different syllabuses, and different exams  (though this argument is usually made by those individuals with a snobbishly high regard for the calibre of their own institution.) Admittedly this system might change in years to come.

There are up to seven extra points given for other degrees, depending on how advanced the degree is (bachelors, masters, doctorate) and its classification. Again the number of points are standardised between degree subjects and institutions and includes intercalated degrees, all of which vary considerably. I spent three years getting a degree in biology. It was quite tough, sometimes it was fun and interesting, and I like to pretend it’s given me some life experience and a bit of a broader knowledge base, but I’m pretty sure that this doesn’t make me a better prospective doctor. Essentially I’m getting rewarded for being indecisive about my career.

Finally there are up to two points available for publications, the same number of points for having your name attached to any pubmed number regardless of its relevance, the quality of content or the journal it's published in. I think this leads to a pretty cynical approach where research is regarded primarily as a means to build and decorate CVs, and it is depressingly a feature of the entire medical career structure.

The situational judgement test (50 points)

The other 50 points come from the situational judgement test (SJT), a curious exam sat by every applicant. It uses 70 multiple choice or ranking-type questions to assess whether a candidate is able to make safe and sensible non-clinical professional decisions.

Here it is theoretically possible to score anywhere between zero and fifty– making this 2 hour 20min exam far more important for the job application process than the performance across an applicant’s entire medical degree (where the difference between top student and bottom student translates to only 10 points).

In reality the SJT isn’t quite so discriminatory; over 80% of applicants are within the 10 point band between 35 and 45, in a negatively skewed approximately bell shaped distribution. The average score in 2014 was 38.95 (SD 4.25). The SJT is perhaps more useful in its function as a safety net - candidates that score very poorly are flagged up to assess whether they are suitable to work as a junior doctor despite being able to complete medical school.

2013 SJT results distribution

Given that I have not taken the test yet (I’ll sit it in January) I can’t really comment on its particulars, but I suppose that I am relatively impartial because it hasn’t been used to assess me yet. The test has been used since 2013, an inauspicious inaugural year that was distressing for the applicants as after jobs had originally been declared the tests were remarked, many scores went up or down and so changed the outcome for many.

The SJT is still a relatively unknown quantity, and as such it is fairly odd that our futures are so dependent on it. The existence of the SJT seems to curiously disincentivise one from working to do well in medical school exams, and adds an almost completely random element to the application process. We are advised that it is a test that is impossible to revise for, but that hasn’t stopped entrepreneurial organisations from offering wide ranges of dubious and expensive preparation materials and training courses.

2) Choice is an illusion

I am chronically indecisive. I have no clear view of where I want to be in five years, or what sort of doctor I want to be (if any: plan A is still scratch card windfall). During my time at medical school I haven’t been able to exclude many specialties from my list of potential jobs or careers and I’m not drawn to any particular part of the country for any reason. Plus some people say I overthink sometimes (see current whinging blog post).  I therefore seem to find the applying for F1 less straightforward than many people I know.

The foundation programme is usually six different 4-month rotations, during each the junior acts as dogsbody to senior doctors in a specific area of medicine. There are several levels of apparent choice at work before a job is allocated, firstly the area of the UK (there are 21 “foundation schools”), the hospital, and the specific clutch of six rotations themselves.

Each coloured block here is a foundation school
The first decision is ranking these in order of preference

So with just these three factors there are many hundreds of possible combinations available to consider. Unfortunately, outside of the hospitals I’ve been placed at around Birmingham I have no knowledge of the relative merits of any other part of the UK, or any other hospitals. And I also have no real knowledge about what are the differences are between different F1 jobs. More uncertainty is introduced because all foundation jobs are “subject to change”; I know of people who ended up frustrated with three completely different FY1 rotations to the three they applied for (and were allocated to).

Further considerations that might affect how much you would want a job include the team you will be working with and the consultant you’d be serving under –unfortunately both of which are impossible to know until you start work. You might also attempt to guess where your friends might end up, which is at least as confusing as attempting to predict the future for yourself.

According to the Mental Capacity Act 2005 (completely unnecessary tenuous reference) a person’s choice is valid only if they fully understand the benefits, risks and alternatives of a decision. I don’t feel at all confident that I meet this charge. There is a huge amount of information online comparing different areas to work by every imaginable characteristic, so much information that it becomes impossible to digest it. Deciding what is important (City or Rural? North or south? Medicine or surgery? Is it too competitive? Known or unknown? Accommodation? Old friends or new people? Things to do outside of hospital? And so on?) is difficult and often arbitrary, and the decision is never completely informed due to the uncertainty that remains as to the true nature of the location, hospital and job you apply for.

Perhaps most confusing is that applicants rank all the deaneries before we know our scores – as mentioned above the SJT is shrouded in mystery and ensures that no one is at all sure how strong their application will be until after the results. Perhaps I’d apply to a competitive deanery if I was sure I had enough points to secure a decent hospital and job were I to get it. But regrettably I still don’t know what I want, and anyway it’s quite hard to even guess which deaneries and which jobs will be competitive since this seems to change a great deal from year to year.

So maybe I'm a little defeatist and pessimistic but I feel completely overwhelmed by the scope of possibility for next year, and I have gained almost no useful predictions as to where I will want to be, what I want to do or what level of control I have in effecting my choices. It’s not ideal that I take the same fence-sitting approach to clinical decisions too. One thing I am sure of is that after what will be seven consecutive years of being a student I’m really looking forward to getting a job. Any job.